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Abstract

Aultman Hospital, Canton, Ohio, is an independent community teaching hospital with 808 licensed beds and 575 active physicians in more than 40 different medical specialties. With the mission to lead its community to improved health, Aultman Hospital aimed to move medication delivery to the bedside, reviewing its entire medication delivery process.

Aultman, which operates under a centralized pharmacy model, had a variety of pharmacy technology systems designed to automate the dispensing and delivery of medication already in place. In addition, the facility had a hybrid system of automated medication storage cabinets and medication carts on some of the floors. To improve existing processes, the hospital needed to add medication storage cabinets on every floor and open an inpatient pharmacy that would be integrated with existing pharmacy systems.

A decision team of nurses, pharmacists, and IT personnel developed a project plan from a multidisciplined approach. Additionally, a process improvement specialist and a vendor helped the team assess the entire process and streamline it from beginning to end.

The initial goals were to replace existing cabinets, decrease the use of med carts, and minimize the number of interface locations, which wouldn't have been possible with more than one system. The hospital already had several integrated products from one vendor, but conducted a thorough review process to ensure they made the right choice.

After deciding which products to use, optimization and medication teams studied and managed the process. Through their work, the processes were streamlined, and the hospital went from having four different procedures to a consistent process across all floors.

One of the challenges was to minimize the time nurses had to travel to get medications from different cabinets, so they could deliver patient care faster. More cabinets on the floors meant increased availability, and the new locations improved nurses' workflow because they no longer had to wait for pharmacy to deliver the medications.

The pockets/drawer configuration was customized to a degree, but the cabinets were designed for the specific needs of each floor. One universal decision was to select totally secure drawers with locking pockets, chosen primarily to prevent diversion.

The new cabinets offered increased capacity, so staff members were able to stock items they couldn't previously house. Additionally, stat meds are now stored in the cabinets; nurses can administer a drug as a STAT med or new med order simply by scanning in the information, improving overall time to care.

Post-implementation perks

The new inpatient pharmacy opened in March 2009, becoming a state-of-the-art automated inpatient pharmacy system that covers everything from medication storage, physician ordering, and patient delivery to dispensing and restocking. With the new system in place for more than a year now, the hospital has seen improvements in pharmacy turnaround time, nursing workflow, and patient safety.

The whole process is driven through a single pipeline, so order filling has become quite efficient. Now instead of faxing orders, all of the med requests come through the scanner. The order immediately appears on pharmacy's screen. Once in the system, the order is automatically sent to the appropriate automation for fulfillment by the robot or carousel. With the exception of I.V. meds, all orders go through the same pipeline, and it has made a huge difference in pharmacy turnaround times. We now have a 60-minute turnaround on new medication orders versus 2 to 3 hours pre-implementation.

Dispensing efficiencies have improved, and Ohio's legal requirements for positive ID have been met with the use of a biometric finger swipe device on the cabinets. The biometric device is used as much as possible; passwords are only used if the user has a weak fingerprint.

Within the cabinets, drawer configuration enhances safety, as well. New high-capacity locking drawers allow only the pocket of the selected medication to unlock. No other medications can be dispensed from any other pockets. This ensures users take out the correct medication and don't pick up a look-alike drug just because it's next to another drug.

Automation, particularly the new bar-code, scanner hand-held device, has facilitated restocking. Everything is bar-coded, and the technicians are required to scan all meds, along with the bar-coded medication pocket, when restocking. This ensures the correct medication and dosage are being stocked in the correct drawers, and it eliminates the inadvertent scanning of the wrong product. We've changed pharmacy quantities because we found we used more on certain floors and have added or removed items based on use. If an item runs low outside of the daily stock, nurses simply use the order refill button on the cabinets to alert pharmacy.

The new cabinets have decreased diversion because getting into the wrong pocket isn't possible. Once a drug is removed from a drawer, the nurse must indicate the quantity, and the final count must be entered before closing the drawer. If there's a discrepancy, staff returns the drug to a secure bin. When meds are missing, an electronic communication is sent to the pharmacy so work isn't disrupted with calls. The new cabinets are integrated with a storage system of locked vaults for controlled substances, providing closed-loop management of narcotics.

The pharmacy has a new software program integrated with the cabinets to help identify potential problems, which makes it easier to find discrepancies and track diversion. A discrepancy error message appears on the bottom of the screen, and reports show who's in the cabinets and the most common drugs they're using. Nurses have the capability to run these reports themselves.

Reporting is an area that's improved by using a single formulary and interface. Having everything in one database as a total system solution makes it easier to produce and access data. Having a single vendor ensures the reports are all in the same language. Because of across-the-board barcoding, staff can generate documentation for regulatory compliance.

Satisfaction: It's in the stats

In the end, though, it all comes down to patient care. And the new cabinets, combined with the bar-coding, have enabled us to address patient needs faster while also improving safety. Staff report little to no near misses due to bedside barcode scanning. Once nurses have the physician order, they go to the cabinet to access the patient's profile and select the med. Nurses then go to the patient bedside and scan the ID band and the bar-coded medication to create the order for administration.

The hospital's scan rate goal is 80 to 85%, with all units at goal or close to it. A monthly report is shared with all unit managers, and we have a process in place if specific personnel aren't meeting the goals. Time of order to time to care has gone from 90 minutes for each segment of the process to a 30-minute turnaround for order review and 30 minutes on med delivery. Pharmacy turnaround time has dropped by 50%. At more than 4,000 orders a day, this has made a huge difference in patient care. Perhaps the biggest achievement in terms of patient safety goals was having patient identification, administration, and documentation of medications all answered with bar-coding and bedside scanning.

From the new pharmacy equipment that dispenses more than 12 million medication doses a year to bedside bar-code medication scanning Aultman patients know they're in the right place for cutting-edge technology. The investment in resources and technology is paying off: For the 14th consecutive year, Aultman Hospital earned the ”Consumer Choice Award” and was named the Canton-Metro area and Stark County's “Most Preferred Hospital for Overall Quality and Image” by National Research Corporation.

Lessons learned: Aultman Hospital's rollout recommendations

1. Do your homework.

To get started, study the present workflow of what people are actually doing. Then look at the future plans of what you want to do. Spend enough time up front looking at the workflow process. Then, compromise on what processes can actually change. Because of our legwork, our workflow has improved by adding more automation to the process. With the scanning of drugs and the changes made, nurses have redefined how they do their jobs. Having an integrated product line and working on the same database backbone has streamlined information-gathering processes and improved productivity for pharmacy.

2. Plan ahead.

You have to put in the time and energy up front to understand the impact it's going to have before implementing automation. You need to do this before you decide on a product, as it impacts your vendor selection.

When we first made the transition to the new automation, there was mass confusion because we didn't really look at the impact on each department, up front. What impact does scanning of orders have on pharmacy? On nursing? Our planning continues to improve with each new product.

3. Define goals.

Every project we've undertaken has come from the top down. Our administration sets the goals, committees are formed, and a project plan is developed. It's important that your goals are both short- and long-term and that the plan has multiple phases. This prevents the team from that overwhelming feeling of trying to tackle everything at once.

4. Choose vendors carefully.

Once the project is determined, look at the available vendors. Vendors should be flexible enough to meet the resources and culture of each organization. Whatever product you pick must work efficiently with your workflow. If the product can't do that, move on. Pick a vendor that will stay involved throughout implementation.

5. Encourage communication.

If we've learned one thing it's that you can never have enough communication! We have what we call a “med informatics group,” which consists of pharmacy, IT, and nursing. It started prior to the project implementation and has evolved into a monthly meeting to discuss issues that surface regarding scanning, stocking, bar-coding, etc. If someone is having a particular problem, he or she can attend the meeting. We work together to uncover the problem and address it as a group so that we can resolve it. It has helped us as departments to communicate at one level and then take it down to the unit level.

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